Inspection on 12/07/06 for Pathways North West

This inspection was carried out on 12th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Pathways North West 175 Blackburn Road Great Harwood Lancashire Lead Inspector Mrs Lynn Mitton Key Unannounced Inspection 12th & 13th July 2006 09:30 Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pathways North West Address 175 Blackburn Road Great Harwood Lancashire Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Pathways North West Ltd Mrs Angela Marie Fletcher Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service is registered for a maximum of 5 service users in the category of MD (Mental Disorder, excluding learning disability or dementia) The service shall employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Newly registered with the Commission in January 2006 Date of last inspection Brief Description of the Service: Pathways Northwest Limited is registered with the Commission for Social Care Inspection to provide personal care and accommodation to 5 adults with mental health problems. The premises are a spacious end-terraced garden fronted property that is situated in a residential area of Great Harwood. The home is adjacent to the town centre of Great Harwood and is close to local amenities. Accommodation is provided in 5 single bedrooms. Shared space is 2 lounges, one smoking area and one non-smoking, a games area and dining room/kitchen. There is private garden area to the rear of the home. The home aims to provide structured rehabilitative support that responds to the needs of service users to help them achieve their maximum potential. There are a range of therapeutic activities i.e. stress management and problem solving available. Fees for the cost of a weeks care at Blackburn Road ranges from £725.00 – £1231.12. There was information available to potential service users advising them of the home and giving them details about the type of service they could expect. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over 2 days. A partial tour of the premises took place. The inspection was conducted with the registered manager, all the service users were also spoken to, one staff member was formally spoken to and interaction between staff and service users was observed, Throughout the report there are various references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of staff member and service users. Records pertaining to these people were inspected, as were policies and procedures. There were 5 service users living at Blackburn Road at the time of the inspection. What the service does well: Fully detailed assessment and social functioning forms were in place to ascertain service users needs prior to their admission to Blackburn Road. One service users relative said; “ the manager and staff team give me peace of mind that I need when my son is in care. I find all the staff and management very competent and sympathetic in the affairs of the clients. In fact in times of crisis, I find comfort in the fact that the best will be done in the interest of the clients”. Comprehensive assessment documents were now in place to ensure that any prospective new service user would have their needs identified accurately and from this it could be decided if Blackburn Road could meet these needs. Service users care plan contained all the relevant health and care information to ensure their needs would be met. The home was run to make sure the service users had opportunities to enjoy their life and to fulfil their potential. Service users had regular access to their local community, and were supported in maintaining family links. Staff spoken to and observed by the inspector demonstrated a good understanding of the needs of the service users. The home was well managed, and recruitment records demonstrated efforts to ensure the safety of service users were in place. Comprehensive assessment documents were now in place to ensure that any prospective new service user would have their needs identified accurately and from this it could be decided if Blackburn Road could meet these needs. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA2 &YA5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Detailed needs assessments were in place identifying the care needs of service users so that support staff would have a clear understanding of how they needed to support them. Contracts explained what service users could expect, and what was expected of them in order for them to live at Blackburn Road. EVIDENCE: Since the home opened in January there had been five admissions to the home. The assessment and social functioning forms in place were seen by the inspector and were considered to be fully detailed documents to ascertain service users needs prior to admission. Service users contracts were seen. These had been signed and dated by the service user, and fully explained the terms and conditions of their residence at Blackburn Road. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA6, YA7 & YA9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information on care and health plans meant that service users’ needs were known to support staff and were being met in a consistent way. Policies and practices enabled residents to make decisions about their lives. The risk assessment and management framework supported residents to take responsible risks. EVIDENCE: One service users care plan was examined. This contained detailed information about the level of support needed for staff to ensure continuity of care and evidence of service users input. The care plan had been reviewed very recently. There was also a copy of a care plan completed by the service users local health authority. The policy of the home was to promote responsible risk taking and freedom of choice. The care plan seen contained risk assessments and management Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 10 strategies. It also contained a safety profile. These documents had been reviewed within the past month. The inspector and registered manager discussed, how further risk assessments may be needed for this service user (e.g. whilst in the kitchen, when cooking, behaviour whilst in the community), however the risk assessment format was excellent. The inspector was advised that all service users had a next of kin or advocate. Residents talked to the inspector, and observations were made, demonstrating a number of ways in which they made decisions about their daily lives. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA12, YA13, YA15, YA16 & YA17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was run to ensure service users had opportunities to enjoy their lifestyle, to fulfil their potential and given opportunities to maintain their independence. They had regular access to the local community, opportunities to maintain family links, their privacy was respected and they were valued as individuals. Individual dietary needs were catered for and they were encouraged to participate in shopping, planning and preparation of meals. EVIDENCE: Each service user had an individual activity programme, which included community-based activities. The inspector was satisfied that these were based on meaningful and valued activities, regularly accessing their local community. One service user was due to begin voluntary work at a local horse and pony sanctuary; another had expressed a wish to seek further education/employment. One service user was due to start further education in the near future. These also endeavoured to ensure service users had Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 12 opportunities to fulfil their potential socially, emotionally, and maintain their independent living skills. The registered manager and inspector discussed how the cultural needs of each service user were met. Most service users have regular contact with their families. One service user was on home leave at the time of the inspection. The inspector was satisfied that service users families were encouraged to be involved in the care planning for each service user. Staff support service users in maintaining family contacts, this included structured family meetings and trips to Scotland to meet up with family. Service users preferred name was included on the care plan documents. Residents said that they felt they were listened to and their rights and wishes were respected. All service users have a key to their own room. One service user needs support with personal care; other service users needing only prompts. All service users opened their own mail. The inspector saw one service user making his own lunch. This person has his own budget, plans his own menu and plans his own meals except tea. Two service users were given a weekly budget to buy their own food at lunchtime. A record of what each service user eats was kept. Residents made their own meals with staff support as required, except tea, which was a communal meal. Meals were discussed at residents meetings. Halal meats were provided for two service users. Service users were advised individually about nutritionally balanced diets for one service user on a weight reduction diet and another who was diabetic. The service user who was diabetic had written dietary advice on her care plan. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA18, YA19, YA20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support was offered in accordance with service users wishes, and in a way that promoted privacy, dignity and independence. Service users health needs were being appropriately recorded and met. Policies and practices for managing and administering medication were in good order. EVIDENCE: The inspector observed that service users received personal support in the way they prefer and require, and individual plans identified service users personal support needs. One service user received 1:1 care support 2 days a week by a care staff who understood the service users cultural needs and could communicate in her first language. All service users had access to specialist workers such as consultant psychiatrists, anger management support groups, abstinence support groups, community psychiatric nurses, and counselling. There was evidence on the care plan case tracked that service users mental health and physical health needs were being given due care and attention. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 14 The service user had a “Staying Well Plan” and a health check in place. These were very detailed documents and had been recently reviewed. These documents needed signing by the service user and dating. Policies and practices for managing and administering medication were in place. Medication was being stored securely and in good order. Medication administration records were seen and in good order. Patient information leaflets were available. Appropriate records were kept of medication returned to the pharmacy. Risk assessments were in place for one service user who checked her blood sugar levels. Consent forms for staff to administer medication were in place. No one self medicates. The district nurse visited the home daily to attend to one service user; there was a plan of care in place in this regard. One resident was self-medicating. A risk assessment had been completed in this regard. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA22 & YA23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a clear complaints procedure and evidence that service users views were sought and acted upon. Staff had a good understanding of adult protection issues, ensuring that any allegations would be dealt with appropriately. EVIDENCE: One service user said that if he had any worries he felt very comfortable talking to staff about them. The Commission had received no complaints. One informal complaint had been made to the home this had been resolved by following the homes procedures. Policies and practices regarding concerns complaints and protection of vulnerable adults were in place, and these included whistle blowing. Staff spoken to by the inspector knew what to do should they have any concerns about service users wellbeing. In house staff training regarding the prevention of abuse had been undertaken during a staff meeting. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA24 &YA30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard of décor and furnishings provided a comfortable and homely environment for residents. EVIDENCE: The home was clean and tidy, and there were no offensive odours. The home was newly registered with the Commission in January 2006 and had been fully re-furbished prior to this. New kitchen and bathroom flooring had been fitted. The smoking lounge had an air purifier in place. A monthly checklist was completed to ensure the standard and safety of the building. Service users told the inspector that staff do not enter their bedrooms unless they have concerns for their safety and wellbeing, and that they (the service users) were in agreement with this. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 17 Service users and care staff cleaned the home. Appropriate laundry facilities were in place to meet the needs of the service users. It is planned to further develop the rear garden with input from the service users. The front garden had attractive summer pots and baskets. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA32, YA34, & YA35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Almost 50 of support staff had completed their NVQ training and other appropriate training was also being undertaken. Recruitment and selection procedures and policies ensured service users were safe. Residents’ needs were met by well trained staff. EVIDENCE: The inspector was advised that out of the team of 7 support staff, two had obtained NVQ2 training qualification. 4 other staff had enrolled on this training which was due to be completed by October 2006. One senior member of staff had recently completed the NVQ level 3 training. All new support staff completed induction training to TOPPSS specification. The inspector case tracked one staff member’s files. This contained information which demonstrated that checks had been taken to ensure that service users were safeguarded. The staffing rota was seen this demonstrated that there were at least 3 members of staff on duty between 9 – 5 pm and 2 staff members between 5 – 10pm and 1 wake and watch person on duty between 10pm – 9 am. 1:1 supervision notes were seen the inspector advised that these should be help on a monthly basis during new staff member’s probationary period. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 19 The last team meeting had been held 31.5.2006 the inspector advised that more detail on the minutes of some of the meetings would be more helpful. Each member of staff had a training and development programme. A training matrix was in place, it was advised that this was in need of updating to ensure its accuracy. Staff training was ongoing and relevant to the resident’s living at Blackburn Road. One senior staff member had recently completed accredited medication training, and a computer skills training course. A Training and Development plan was in place, as was an allocated budget as identified in the business plan. Individual training needs were identified during staff appraisals. The inspector observed residents’ being supported by competent staff. The inspector spoke at length to one member of staff who was very enthusiastic about his job. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA37, YA39 & YA42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an experienced and competent manager. The home was run to ensure the safety and welfare of residents and staff were safeguarded. Good practice was in place with regard to the safety and welfare of the staff and residents. A system for obtaining the views of residents was in place. Health and safety procedures were in place but staff were not trained in fire prevention. EVIDENCE: The registered manager had completed her NVQ4 training. The inspector was satisfied that there were clear lines of accountability within the home and with the registered person. An annual development plan was in place and seen by the inspector. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 21 A service users survey had not yet taken place. The inspector was advised that it was intended to conduct a survey with service users, and their supporters within the next 6 weeks. The inspector distributed the Commissions surveys to service users. All gas and electrical certificates were in place following the registration of the home in January 2006. Hot water temperatures were checked and recorded weekly. Fridge and freezer temperatures were checked and recorded daily. Appropriate accident records were being completed. Fire evacuation drills were completed monthly, and fire alarm tests were completed weekly. Staff spoken to knew the fire procedure. The inspector noted that most staff had undertaken health and safety training as outlined in this standard to ensure the safety of the service users. Those who have training outstanding had been booked to attend the outstanding courses within the next three months. Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 3 X 3 X X 3 X Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 23 Not applicable Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13 (4b) Requirement The registered person shall ensure that any activities in which service users participate in are so far as reasonably practicable free from avoidable risks. The registered person must provide training appropriate to the work they are to perform. Timescale for action 29/09/06 2 YA32 18(1) 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pathways North West DS0000066446.V291945.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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